A. Loyola Sánchez et al / Reumatol Clin. 2009;
Joint degenerative disease (JDD) is a chronic and degenerativeaffection of all of the joint structures, which starts as damage to thecartilage and progresses though a dynamic adaptation response,leading to irreversible structural change.
According to the data from the Framingham study, kneeosteoarthritis occurs in at least 33% of persons 60 or older
and isthe main cause of joint inflammation in the United States, with aprevalence of 12%.
With respect to non-pharmacologic treatment, therapeuticultrasound (TUS) is an important tool, which favors cartilageregeneration.
TUS is based on the emission of mechanical waves of frequenciesover 16
000 Hz, which interact with the bodily tissues and lead tovibrations of an elevated frequency, resulting in either a thermal ora mechanical effect.
In order to achieve the mechanical effect, thesound wave must be applied as a pulse and at a low intensity.In the medical literature there is ample evidence for themechanical effect of low-intensity and pulse ultrasound which favorscell metabolism and the capacity of tissue regeneration.
Studies in humans have shown a beneficial effect on bone healingin fractures when using this treatment modality,
making theapplication of pulse therapeutic ultrasound (PTUS) useful in tissuessuch as joint cartilage by producing a regenerative effect.On the other hand it is important to mention that TUS in generalis better diffused in liquid environments (with a high water content),such as in the case of the knee.
Several studies have shown a positive effect of PTUS on theproliferation of stromal cells and chondrocytes, as well as in thedifferentiation of mesenchymal stem cells
; there is also an effecton metabolic stimulation and the formation of extracellular matrix inchondral tissues and an improvement in the histological appearanceof total osteochondral damage in animals.
Cook et al demonstrated a positive effect of treatment withPTUS on joint cartilage in the repair of osteochondral defectsinduced in the knees of rabbits: they applied a dose of 36 to72 J/cm
daily for 3 months and reported both macroscopic andhistological benefits.
Until today there are no studies on the effect of PTUS on jointcartilage in patients with knee osteoarthritis. Therefore, the objectiveof this study is to investigate the effect of this treatment modality onthe thickness of the joint cartilage, pain and function of patients withknee osteoarthritis stage 2 and 3 according to the classification of Kellgren and Lawrence.
Material and methods
Observational, before and after study, without a control group.
The study group was composed on 10 patients who belonged tothe Instituto de Seguridad y Servicios Sociales de los Trabajadoresdel Estado (ISSSTE) health system: nine women and 1 man, meanage 67.18 years with an age range of 56 to 81 years of age, with adiagnosis of knee osteoarthritis (according to the criteria of theAmerican College of Rheumatology)
stages 2 and 3 (according tothe classification by Kellgren and Lawrence)
, recruited in the periodbetween March 1, 2007 and May 30, 2007, sent by the departmentsof Rheumatology, Geriatrics, Orthopedics and Physical Rehabilitationof the Centro Médico Nacional (CMN) 20 de Noviembre.The exclusion criteria were to be carriers of an inflammatoryrheumatic disease, having undergone a knee infiltration in the12 weeks prior to the study and to have any formal contraindicationfor the performance of a Magnetic Resonance (MR) imaging study.This study was approved by the Ethics committee of the CMN20 de Noviembre.
Measured using a 10 cm visual analog scale (VAS) (EVA) on2 occasions: 10 cm on 2 occasions: one day before the start of treatmentand one after the application of session number 36 of PTUS.
A severity index of Lequesne
was employed one day before thestart of treatment and one day after session 36 of PTUS. A reductionin 3 points was considered as important clinical improvement, inaccordance to what has been reported in the literature.
Thickness of joint cartilage
Two images were performed (pretreatment and post-treatment)using MR with an Intera set of 1.5 Tesla, 3D/WATSc sequence in acoronal projection, T1 FFE TR 20 TE 10 and Flip 25 technique, obtaining30 coronal slices of 3 mm thickness on the examined knee. Positionof the knees was taken into account (flexion and rotation angles)with the objective of obtaining post-treatment images comparableto the initial ones (using real-time comparisons).Once the images had been obtained, they were printed onphotographic paper but not labeled and taken to 2 independentobservers of the Hospital General de México (J.C. and C.H.C), who didnot know the origin, pretreatment or post-treatment stages of theimages, and to an expert in the interpretation of MR in soft-tissues(Judith Vázquez Zamudio) at the CMN 20 de Noviembre.These observers performed the measurement of joint cartilagethickness in randomly assigned but symmetrical areas in the imagescorresponding to the same patient and on paper using scale measuring
Se utilizaron pruebas estadísticas no paramétricas de Wilcoxon y pruebas de correlación de Spearman, y sedefinió un valor de p < 0,05 como estadísticamente significativo.
Se observó una disminución en la intensidad de dolor (basal media de 7,09
2,54; final mediade 4,18
2,22; p = 0,005) y una mejoría en cuanto a la funcionalidad (basal media de 10,55
5,42; finalmedia de 574,45; p = 0,008) después del tratamiento con USTPBI. Con respecto al grosor medido en la RM,no se obtuvieron mediciones consistentes entre los observadores, por lo que se concluyó que el método demedición no fue reproducible, lo que hizo difícil definir si hubo un incremento o no en el grosor del cartílagoarticular.
El USTPBI tiene un efecto benéfico sobre la disminución del dolor y la mejoría de la funcio-nalidad. Desafortunadamente, en este estudio no se cuenta con un método de medición reproducible paraarrojar una conclusión válida en cuanto al efecto del USTPBI sobre el grosor del cartílago articular© 2008 Elsevier España, S.L. Todos los derechos reservados.
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